The provision of quality health care depends critically on timely and easy access to information that is most relevant to the patient's current condition. Computer-based clinical documentation systems have helped health care providers overcome many of the shortcomings of a paper-based system, including accessibility, portability, security and usability. However, as with any technological advance, the implementation of computer-based patient records has not only created new problems, but has also raised expectations about how health care information can be used in such a way that many of the known solutions and approaches are now seen as problematic.
The successful implementation of computer technology by health care providers demands that they acquire computer skills that many providers view as an infringement upon their primary purpose in seeing and treating patients. The demand for new skills and corresponding frustration is exacerbated by the increased expectations about the amount of patient information that should be recorded and available for use during any given patient encounter. The fact that a computer-based patient record presents a health care provider with a much larger set of potential information creates a corresponding imperative to both record and review more information while providing a patient's care. The problem is that eventually, the computer interface for accessing this wealth of information becomes nearly as cumbersome to deal with as a paper chart. Typing to enter information while clicking or scrolling through a myriad of windows, forms or screens can be as distracting and nearly as inefficient as flipping through pages of paper.
Existing computer-based record systems have partially resolved this problem by limiting the amount of manual typing and navigation required to access and record information for a given patient visit. A typical solution is to provide a summary of key data elements in a single window and to collapse access to the underlying data into a hierarchical navigation interface. The interface allows users to drill down to a specific data element by pointing and clicking within the interface, and to enter data by the same means. By presenting users with rapid access to information that is most relevant to their current patient visit, these solutions make it easier for health care providers to use and add to the information available within a computerized patient record. In order to ensure that these ease-of-use features remain flexible for use among diverse health care providers with even more diverse patient populations, it is even more desirable to embed these features as templates within the user interface. A template-based approach allows providers to choose from a number of different summary/navigation views and use the one that is most appropriate for the given circumstances.
However, this solution is ultimately unsatisfactory, because of the frequency with which health issues will arise that a template was not designed to address. The obvious attempts to resolve this difficulty also prove unsatisfactory. First, simply creating more templates means that the provider will face the problem of knowing the differences between each template in advance, and the choice may ultimately prove unsatisfactory anyway. For example, you could create a number of different variations of each standard template, but in order to use this set of variations efficiently you would have to be familiar with the specific differences between each template. And even if you choose what looks to be the right template at the start of a visit, you may uncover information in the course of that visit that is no longer easy to capture with the original template. Second, building more complexity into a smaller set of templates tends to defeat the purpose for having templates in the first place. The more complexity you add to a standard template, the more it looks like the complex system that the template is intended to simplify. Third, allowing a user to embed dictated notes to extend the usefulness of any given template undermines some of the advantages afforded by using a computerized record in the first place. Dictated notes must be transcribed if they are to be viewable online, and the elimination of transcription costs is one of the major benefits associated with implementing a computerized health record system. Even if you manage to successfully automate the transcription process, you lose the benefits associated with storing visit information as structured data. Dictation blocks of text, because they are unstructured (i.e., are filed in the database as free text rather than as discrete data items such as diagnosis codes), are unavailable for use in decision support, data mining and reporting.
So even with the above-listed improvements, the tension between ease-of-use and flexibility for recording patient encounter information persists within existing solutions to providing a computerized patient record. The objective of the present invention is to provide a computerized patient record system that takes full advantage of an easy-to-use navigation interface and summary view but which does so without sacrificing the flexibility and power associated with a robust database of information.